Dosimetry Application Form (UW Health) Dosimetry Application Form UW Health Section 1: Personal IdentificationI will work with* Radioactive Materials X-Ray Producing Machines UW Health Employee Radiation Safety Dosimetry TrainingFor training: 1. Log into U-Connect, go to “Quick Links” 2. Go to “U-Learn” under “General Links” 3. Click the magnifying glass in the upper right corner 4. Search for “UW001409” 5. Register and Launch “Radiation Safety-Dosimetry” 6. Take and pass the short quiz at the end of the course Date Taken: MM slash DD slash YYYY Access Community Health Center Employee Training (Not for UW Health Employees)For training: 1. Take the mandatory training: Access Community Health Center Dosimetry Training 2. Confirm date below Date Taken: MM slash DD slash YYYY Name* First Middle Last Gender*FemaleMaleDate of Birth* MM slash DD slash YYYY Department* Email* Phone*Section 2: Employment InformationI am a:* Full-Time Employee Temporary Employee Student Employment Start Date* MM slash DD slash YYYY Employment End DateIf Applicable MM slash DD slash YYYY I was previously badged at:*Please check all that apply. UW-Madison UW Hospital UW Medical Foundation None of these; I was not previously badged Other Previously badged at Other - please explain* Other employment involving radiation exposure:*Are you currently or have previously worked with radioactive material or radiation producing machines and have been monitored for radiation exposure? Yes, but not within this calendar year Yes, within this calendar year (copy & paste: https://ehs.wisc.edu/request-for-previous-dose-history-form/ and fill this form out after you submit the application) No Department employed in:* Access Community Health Center Cardiology Family Medicine GI / Urology Nursing Oncology Orthopedics Pulmonary Radiology Surgery / Operating Rooms Access Community Health Center* ACC - Access Comm Health Center - Lindsey Miller Cardiology* CAL - Cardiovascular Laboratory (Cath Lab) - Cara Miller CF – Cardiology Fellows – Cara Miller EC - Electrocardiography - Suzanne Klingaman SON - ECHO/Vascular Lab - Tracy Mayne-Walker Family Medicine* BLC - Belleville Family Medicine - Erica Dill FM - Wingra Family Medicine - Ashley Getter FP1 - Family Practice Northeast - Ashley Getter FP2 - Family Practice Verona - Elena Prozorova GF - Generations Fertility Care Clinic - Barb Schulz GI / Urology* GU1 - GI & Urology Clinic - Joy Schluckebier GU3 - GI & Bronchoscopy APC - Kelly Pirkel MGI - Meriter GI Physicians – Amy Tatro Nursing* ACH - American Family Children’s Hospital (P4) - Carrie Cronk CRU - Clinical Research Unit - Tammy Kiger DLS - Dialysis - Jon Haas F66 - F66 Nursing Ward - Kit Soper NR1 - Nursing Services - Christine Spier Oncology* CCU - Cancer Clinic Chemo Unit (Lutathera) - Kendra O’Connell JCC - Johnson Creek Cancer Center - Dawn Klecker RTH - Human Oncology (Radiotherapy) - Jami Wood Orthopedics* OT - Orthopedics - Beth Lalor Pulmonary* MPU – Meriter Pulmonary – Amy Tatro Radiology* CT - Computed Tomography (CT) - Andrea Rausch ESC - East Clinic Radiology Department - Carrie Hamielic DVC - Interventional Radiology Tech's - Jaime Nodolf MAC - Mammography (Breast Center) - Johannah Kereven MP2 - Medical Physics (PET Tracers) - Christine Jaskowiak MP5 - Medical Physics (Molecular Imaging) - Christine Jaskowiak NM - Nuclear Medicine (University Hospital) - Rhonda Denu TNM - Nuclear Medicine (The American Center) - Chris Goetsch RD1 - Interventional Radiology - Alan Farnsworth RD2 - Radiology (Faculty/Fellows) - Alan Farnsworth RD3 - Radiology (Residents) - Maggi Schrader RD4 - Radiology (UWHC Diagnostic Radiology) - Brett Wehmeyer RD6 - Radiology (UWHC Clinics) - Mary Gehin RT1 - Radiologic Technology - Renee Richardson TAC - The American Center (Imaging / Diagnostics) - Tracy Ellis WSC - West Side Clinic (Diagnostic Radiology) - Karmen Shoys WS1 - West Side Clinic (Bone Mineral Density) - Brenda McCarney Community Radiologists Interventional Radiologists Community Radiologists* FTA - Fort Atkinson Healthcare - Cathy Hovel MAQ - Mauston/ Mile Bluff - Felicia Abbott MEQ - Meriter Hospital - Amy Tatro RHQ - Richland Center Hospital - Jeremy Pauls TA2 - The American Center - Tracy Ellis UF0 – UWMF Radiology (Medical Imaging/Nuclear Medicine – chest) – Kari Pulfer UF1 - UWMF Radiology (Medical Imaging - collar) - Kari Pulfer Interventional Radiologists* CAL - Cardiovascular Lab: Cath Lab - Nicole Heininger MAM - Mauston/Mile Bluff - Felicia Abbott MEM - Meriter Hospital - Amy Tatro RD1 - Radiology (University Hospital) - Alan Farnsworth VAM - VA Hospital - Diane Meranda VS- Vascular Surgery - Jacqui Huebner Surgery / Operating Rooms* ANT - Anesthesiologists - TBD CHS - American Family Children’s Hospital Surgery - Aimee Muchie MOR - Meriter OR Physicians – Amy Tatro OR - Operating Rooms - Peripheral Vascular – UWHC - Tim Schneller ORO - Operating Rooms – Orthopedics - Aaron Signer OS - Outpatient Surgery - Ashley Ring SU3 - Surgery (Voice & Swallowing) - Bryn Olson-Greb TAC - TAC OR - Tracy Ellis TSC - Transformations Surgery Center - Erin Hernandez UF2 - Madison Surgery Center - Tammie Schroeder UF3 - Madison Surgery Ctr (Providers) - Tammie Schroeder VS - Vascular Surgery - Jacqui Huebner By Signing this Form, I Attest to the Following:1.* I will exchange my badge on time and return it to my badge group leader upon resignation. 2.* I certify that the information on this application is correct and complete, to the best of my knowledge. 3.* According to DHS 157.22(5), I hereby request and authorize my previous employer(s) to release my dosimetry records. 4.* I certify my dosimeter(s) will only be worn at UW facilities and will also remain in this sub-account I am applying for and not be used in any other location. Employee Signature* Signature Date* MM slash DD slash YYYY Supervisor Name* First Last Supervisor Signature* Note: Names may be typed into the signature field. Inclusion of the signature or typed name of a UWHC supervisor indicates their knowledge of, and consent to, the submission of this form.